7197063

Hindawi
Journal of Ophthalmology
Volume 2019, Article ID 7197063, 6 pages
https://doi.org/10.1155/2019/7197063
Clinical Study
Long-Term Results of Autologous Auricular Cartilage Graft
Applied in Anophthalmic Orbits Unable to Wear Prosthesis
Yi-Lin Liao ,1,2 Shu-Ya Wu ,3 and Yueh-Ju Tsai
1,2
1
Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
College of Medicine, Chang Gung University, Taoyuan, Taiwan
3
Department of Ophthalmology, Taipei Tzu Chi Hospital, New Taipei City, Taiwan
2
Correspondence should be addressed to Yueh-Ju Tsai; [email protected]
Received 5 November 2018; Accepted 24 March 2019; Published 9 April 2019
Academic Editor: Michele Figus
Copyright © 2019 Yi-Lin Liao et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In anophthalmic patients, shallow lower fornices make wearing ocular prostheses impossible and maintaining normal social
activities difficult. This study retrospectively investigated the long-term surgical outcomes of autologous auricular cartilage
grafting for contracted orbits. From 1995 to 2013, 29 anophthalmic contracture sockets with inadequate lower fornices and poor
prosthesis retention presented to Chang Gung Memorial Hospital in Linkou, Taiwan, were treated using this surgical method. The
success rate, aesthetic outcome, recurrence, and complications were analyzed. Among the 29 patients, 15 were women, 14 were
men, their mean age was 45 years, and the mean follow-up time was 52 months (range � 6–159 months). Satisfactory lid position
was achieved in 25 cases (86%), and lower fornix retraction recurred in four cases (14%). Neither donor site morbidity nor
auricular deformity was noted during the follow-up period. Therefore, an auricular cartilage graft can be used successfully as a
compatible spacer for anophthalmic patients with shallow lower fornices and prosthesis-fitting problems in long-term follow-up.
1. Introduction
Anophthalmic patients who wear an ocular prosthesis often
experience orbital and eyelid abnormalities, such as enophthalmos, upper eyelid ptosis, deep superior sulcus, lower
eyelid malposition, and shallow lower fornix. These symptoms constitute what is referred to as postenucleation socket
syndrome (PESS) [1]. To manage these cosmetic disfigurements, multiple surgeries may be conducted in anophthalmic
orbits. First, patients presenting with a volume deficit undergo
correction with a secondary implant (if no implant is present)
or with an orbital floor implant (if a small intraconal implant
is present) before any eyelid surgery [2]. In the past, lining
deficits were corrected by ocular surface reconstructions and
posterior lamella lengthening procedures with various
spacers. However, using an orbital implant to correct
enophthalmos may compromise the depth of the lower fornix
if implant migration or protrusion occurs. Therefore, such
patients might be unable to wear prostheses in daily activities
and present to clinics with socket contracture.
Socket contracture ranges from mild-to-moderate and
severe forms. Mild contracture refers to cicatricial entropion
of the lower eyelids caused by fibrotic contracture in the
posterior lamella. Cases whose contracture of the inferior
fornices leads to the inability to maintain an ocular prosthesis are categorized as moderate socket contracture. Severe
socket contracture manifests as marked vertical and horizontal forniceal contracture [3] and may occur following
trauma, recurrent inflammation caused by an inadequate
prosthesis, or radiotherapy.
An ongoing challenge for surgeons is developing a
method to reconstruct moderate to severe contracture
sockets with a lining deficit of the fornix, especially in nonCaucasian populations with prominent fibrosis tendency.
Both scarring of the orbital fibrous connective tissue and
disturbances to the conjunctiva contribute to socket contracture. Therefore, this study aims to report surgical outcomes for the use of autologous auricular cartilage grafting
for moderate socket contracture in non-Caucasian populations as a reference for further studies.
2
Journal of Ophthalmology
2. Materials and Methods
We performed a retrospective review until 2017 of the
medical records of patients who underwent fornix reconstruction with autologous auricular cartilage grafting by
four surgeons at the Ophthalmic Plastic and Reconstructive
Clinic of Linkou Chang Gung Memorial Hospital, Taiwan,
from 1995 to 2013. The criteria for patient selection were
anophthalmic patients with prosthesis-fitting problems,
lower shallow fornices, and autologous auricular cartilage
grafting. Posterior lamella lengthening surgery with auricular cartilage grafting was arranged after informed consent
was obtained. The prostheses were made by the same ocularist. Patients with a follow-up period of less than
6 months and a history of lower fornix reconstruction were
excluded. The study was approved by the Institutional Review Board of Chang Gung Medical University.
The causes of anophthalmic status, operation history,
and lower lid malposition were investigated prior to surgery
(see Table S1, the study database in Supplementary Materials). We classified patients into two groups: group 1
comprised those unable to wear prostheses and group 2
comprised those who wore prostheses with an upward-gaze
pattern. Furthermore, we recorded the position of the
prosthesis relative to the lower eyelid, supplemental lid
surgery, any complications, and donor site morbidities after
follow-up until the end of 2017.
The authors took preoperative and postoperative photos
of the patients in sitting and primary gaze positions; they
also measured the position of the lower eyelid in millimeters
using Adobe Acrobat Pro IX (version 9.0.0; Adobe, San Jose,
CA, USA) from the inferior limbus to the lower lid margin in
each photo. To increase measurement accuracy, these
photographs were uniformly adjusted for size ratios. The
corneal horizontal diameter (Y), which is relatively constant
in the eyes, was also measured. The reported mean corneal
diameter among Chinese people is 12 mm [4]; the lower
scleral show (X) was adjusted accordingly (Figure 1). Success
was determined when the patient could wear an averagesized prosthesis without regrafting.
Scleral show (X) is the difference between real-MRD2
and standard-MRD2, and Y is the horizontal corneal diameter; real scleral show (mm) X/Y × 12.
Statistical analysis was conducted using SPSS version
23.0 (SPSS, Chicago, IL, USA), and p < 0.05 was considered
statistically significant. We used chi-square tests to compare
the dislocation group with the upward-gaze group in terms
of the necessity of additional lid procedures. Survival
analysis was applied to the differences in surgical success
between the two groups with the log-rank test.
3. Surgical Techniques
The shallow conjunctival cul-de-sac was infiltrated with 2%
xylocaine and 1 : 200,000 adrenaline. A transconjunctival
incision was made to release cicatricial adhesion of the lower
lid (Figure 2(a)). After measuring the conjunctival gap, we
harvested a cartilage graft from the scaphoid fossa of the
donor ear. The skin and perichondrium were dissected to
r-MRD2
s-MRD2
Figure 1: Lower lid real scleral show calculation.
expose the anterior surface of the scaphoid fossa after infiltration of local anesthesia. Subsequently, an ideal auricular
cartilage strip was incised and harvested (Figure 2(b)) [5].
The preauricular skin wound was closed with absorbable 5-0
polyglactin 910 interrupted sutures and compressed using a
beta-iodine cotton ball to prevent hematoma after surgery.
The cartilage graft was sutured between the tarsus and retractor with absorbable 6-0 polyglactin 910 continuous
sutures (Figures 2(c) and 2(d)).
The graft was anchored to the anterior lamella of the
lower lid with two absorbable 5-0 polyglactin 910 sutures
(Figure 3), and a conformer was inserted to maintain the
graft at a position proximal to the vascular bed and deepen
the lower fornix. Next, the traction suture was made upward
to the brow for 2 weeks during the rapid wound-healing
phase. In our technique, the steps crucial to our surgical
success were the anchoring procedures from posterior to
anterior lamella, conformer insertion, and traction suture.
Postoperative follow-up evaluations were performed at
2 weeks, 4 weeks, 3 months, and 6 months.
4. Results
In total, 29 anophthalmic patients (29 eyelids) underwent
lower fornix reconstruction with autologous auricular cartilage grafting from 1995 to 2013. Patients’ ages ranged from
10 to 87 years (mean 45 years): 14 were men and 15 were
women. All surgeries were performed under local anesthesia,
except for those of two children. The mean length of
postoperative follow-up was 52 months (ranging from 6 to
159 months). Table 1 summarizes the demographic data of
these patients as well as their anophthalmos etiologies. The
most common etiology of anophthalmic status was trauma
(69%), and others included malignancy (17%), congenital
anomaly (10%), and endophthalmitis (4%).
In addition, we investigated the precipitating factors of
shallow lower fornix, such as previous enophthalmos correction, radiation, chronic socket inflammation, orbital
implant exposure, and orbital implant migration. The most
common cause of the shallow lower fornix was previous
enophthalmos correction with orbital floor implant (17%),
and other causes were contracture sockets with history of
implant exposure (7%) and irradiated sockets (7%). Table 2
summarizes the prosthesis status and lower scleral show
before and after surgery. In the dislocation group (group 1),
the preoperative lower scleral show was unmeasurable because of loss of the lower fornix. After auricular cartilage
grafting, the amount of lower scleral show was reduced to an
average of 0.18 mm. In the upward-gaze prosthesis group
(group 2), the amount of lower scleral show was reduced
Journal of Ophthalmology
3
(a)
(b)
(c)
(d)
FIGURE 2: Surgical procedure of lower fornix reconstruction in anophthalmic sockets. (a) Making a conjunctival incision to release the
adhesion of the cul-de-sac. (b) Harvesting the auricular cartilage graft from the scaphoid fossa. (c) Suturing the conjunctival edges to the
auricular cartilage graft with a running 6-0 polyglactin 910 suture. (d) Cartilage grafting to restore the space of lower shallow fornix.
(a)
(b)
(c)
Figure 3: Sagittal view of lower fornix reconstruction with auricular cartilage graft. (a) Lower shallow fornix. (b) The dissection plane is
represented by the dotted line. (c) The auricular cartilage graft was fixed to the anterior lamella, providing a proper space for wearing a
prosthesis.
4
Journal of Ophthalmology
Table 1: Demographic characteristics of the anophthalmic patients in this study.
No. of patients (%)
Age
Sex
Etiology of anophthalmos
Follow-up time
Years
Male
Female
Trauma
Malignancy
Congenital anomaly
Endophthalmitis
Months
Mean
44.69
Range
10–87
52.45
6–159
14 (48)
15 (52)
20 (69)
5 (17)
3 (10)
1 (4)
Table 2: Preoperative lower sclera show, additional lid surgery, and surgical outcomes.
Prosthesis status
No. of patients
Lower sclera show (mm)
Supplemental lid surgery
Success rate
Pre-op
Post-op
Lateral tarsal strip/FTSG
Group 1
Dislocation
11
N/A
0.18 ± 0.60
6/11 (55%)
9/11 (82%)
Group 2
Upward-gaze
18
1.86 ± 0.90
0.11 ± 0.30
4/18 (22%)
16/18 (89%)
Overall
10/29 (34%)
25/29 (86%)
N/A: unmeasurable.
from 1.86 mm to 0.11 mm postoperatively. Thus, performing
additional lid procedures such as lateral tarsal strip, horizontal shortening, and a full-thickness skin graft seemed
more necessary in the dislocation group (55%) than in the
upward-gaze group (22%).
Surgical success was defined as the graft taking well
(Figure 4) and strong prosthesis retention after auricular
cartilage grafting without a regraft procedure during followup. The difference in the success rate between the
dislocation and upward-gaze groups was not statistically
significant, with a mean follow-up of 52.45 ± 48.95 months
(range � 6–159 months) (p � 0.567). Thus, ocular prostheses
can not only be maintained in an optimal position but also
with a high level of symmetry to the other eye after lower
fornix reconstruction with auricular cartilage grafting
(Figure 5).
No donor site morbidity concerning the ears was reported during our long-term follow-up (Figure 6). Only
minor complications, such as six lower fornix granulomas
and one lower lid induration, were observed in the 29 cases.
Most cases of pyogenic granuloma occurred 5–8 weeks after
surgery and were easily treated with direct excision and
topical mitomycin C.
Figure 4: Auricular cartilage graft that took well after surgery.
(a)
5. Discussion
Lower fornix contracture in anophthalmic sockets often
prevents patients from comfortably wearing ocular prostheses and affects their quality of life. To address this
problem, many types of lower fornix reconstruction with or
without grafts have been adopted. Sockets with minor
contracture and only a short posterior lamella could be
treated with marginal rotation and transverse blepharotomy.
In sockets with moderate contracture, a shallow fornix, and
inadequate conjunctival lining, mucous membrane grafts
with silicone stents to the rim or conformers were used [6].
(b)
Figure 5: External photography before and after surgery. (a) 21year-old woman had prosthesis dislocation on the left side. (b) Both
prosthesis retention and symmetry of the eyes were improved
6 months after surgery.
Furthermore, various spacers have been used to lengthen
the posterior lamella of the lower lids; autologous grafts have
included the hard palate mucosa, tarsus, oral mucosa
Journal of Ophthalmology
Figure 6: Close-up photo of an ear 2 weeks after cartilage grafting.
membrane, dermis fat, radial forearm free flap [7–12],
chondrocutaneous graft, and auricular cartilage graft [13–
15]. Homologous grafts, such as amniotic membrane grafts,
sclera, and fascia lata [16, 17], have also been applied as
spacers to reconstruct retracted lower lids. Some surgeons
have used synthetic spacer materials such as the acellular
dermis graft and rigid, nylon, foil-anchored e-polytetrafluoroethylene stenting [18–20].
Thus far, no particular type of graft has been considered
ideal or perfect for anophthalmic sockets; therefore, many
types of grafts have been used as spacers for repairing lower
lid retraction. Moreover, grafts have been used in repairing
the lower lid retraction of sighted eyes. Some studies have
explored the success rate of mucous membrane grafts in
sighted eyes, but few have focused on the success rate of
mucous membrane grafts for anophthalmic patients after
long-term follow-up.
The success rate of hard palate grafts in displaced lower
eyelids has ranged from 80% to 85% [7, 21]. In Holck’s study,
satisfactory lid position was achieved after hard palate
grafting in 8 out of 10 anophthalmic sockets. Amniotic
membrane grafting in 10 sockets with mild-to-moderate
contracture provided comparable results to the oral mucosa grafting in Bajaj’s 6-month follow-up study [10]. In
2008, Smith and Malet published a report stating that auricular cartilage grafting had a correction success rate of 92%
among Caucasian anophthalmic patients who had lid retraction during an average follow-up of 19.7 months
(range � 5–55 months) [15].
In the present study, the successful correction of 86% of
29 anophthalmic sockets was achieved through autologous
auricular cartilage grafting after an average follow-up of
52.45 months. Thus, auricular cartilage, which possesses
numerous beneficial characteristics, could serve as a lower
lid spacer in non-Caucasian contracture sockets. The auricular cartilage harvested from the scaphoid fossa had a
more appropriate curvature to fit ocular prostheses than did
that from the concha area in the lower lid fornix. Moreover,
it provided tailored sizes for individuals who required socket
reconstruction. The surgical field was clear from the anterior
approach, and harvesting auricular cartilage from the
scaphoid fossa could be easily performed. After all adhesions
at the shallow lower fornix were released, the auricular
cartilage could offer an excellent scaffold for promoting
conjunctiva re-epithelization.
5
Acellular dermis contracts significantly more hard palate
mucosa when used as a lower eyelid spacer graft [18].
Compared with hard palate mucosa grafts, auricular cartilage grafts are more rigid and durable against contracture
during the wound-healing process in non-Caucasian populations. They can also provide stable support for lower lids
without absorption [22]. Furthermore, neither donor site
morbidity nor functional change of ears has been reported so
far. One study reported uncomplicated postoperative donor
site bleeding in hard palate mucosa grafting [23], but this did
not occur in our auricular cartilage grafts. Postoperative
donor site care is simple, and patients’ recovery time is short.
A minor postoperative complication might be pyogenic
granuloma within 2 months, which can be treated easily.
Malignant changes after wearing prostheses for long term
should be monitored if multiple recurrent episodes of ocular
prosthesis dislocation occur following reconstruction. Because of the limitations of this retrospective study, the
follow-up time varied from 6 to 159 months after medical
records were reviewed. Thus, a further prospective study
with a large series should be conducted to avoid loss to
follow-up bias.
In conclusion, an auricular cartilage graft can be used
successfully as a compatible spacer for non-Caucasian
anophthalmic patients who exhibit shallow lower fornices
and prosthesis-fitting problems at long-term follow-up. This
graft offers not only lengthening of the posterior lamellae but
also walling of the fornix to maintain a proper space for the
prosthesis. It is a surgeon-friendly procedure for restoring
patients’ quality of life without cosmetic disfigurement or
donor site morbidities.
Data Availability
The statistics data used to support the findings of this study
are included within the supplementary information file.
Conflicts of Interest
The authors have no commercial interest in any of the
materials and devices described in this article.
Supplementary Materials
In supplementary table S1, we show the database of our
clinical study. This provides additional information regarding past histories, previous surgeries, and postoperative
complications. (Supplementary Materials)
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